Applicant Information: Please attach proof of residency.

Last Name

First

M.I.

Date

Street Address

Apartment/Unit #

City

State

ZIP

Phone

E-mail Address

Talent Description:

Social Security No.

Drivers License No.

Have you competed in a pageant before:

                                                                         Where:

Are you a citizen of the United States?

YES 

NO 

Current Age:

Will you submit to a background check?

YES 

NO  

Possible Platform Topic:

Have you ever been convicted of a felony?

YES 

NO 

Can you travel?  

I am aware that each contestant is responsible to find their own

sponsor: (circle one)   YES   NO   Initial Please: _____________

Early Registration Discount Expires on 9/20/2010.

Early Registration is only $200.00.

Do you currently have a sponsor for the pageant: (enter name here) __________________

I am aware that each contestant is responsible

for selling (30) event tickets:   YES    NO    Initial Please: ___________

I agree to find my own sponsor: (signature please) _________________________________

I agree to sell my event tickets: (signature please) _________________________________

Tickets are distributed at orientation. Initial Please: _____________

All ticket monies are due & payable on 3/1/2011 Initial Please: _____________

Education: Please attach last report card.

High School

Address

From

To

Did you graduate?

YES 

NO 

Degree

College

Address

From

To

Did you graduate?

YES 

NO 

Degree

Other

Address

From

To

Did you graduate?

YES 

NO 

Degree

References

Please list three references.

Full Name

Relationship

Company

Phone

(           )

Address

Full Name

Relationship

Company

Phone

(           )

Address

Full Name

Relationship

Company

Phone

(           )

Address

Previous Related Experience or Employment: Please attach proof of employment.

Company

Phone

(           )

Address

Supervisor

Job Title

Responsibilities

From

To

Reason for Leaving

May we contact them for a reference?

YES 

NO 

Company

Phone

(         )

Address

Supervisor

Job Title

Responsibilities

From

To

Reason for Leaving

May we contact them for a reference?

YES 

NO 

Company

Phone

(         )

Address

Supervisor

Job Title

Responsibilities

From

To

Reason for Leaving

May we contact them for a reference?

YES 

NO 

Other information you think we should know:

Disclaimer and Signature

I certify that my answers are true and complete to the best of my knowledge.

If this application leads to becoming a contestant with the Brea Scholarship Pageant, I understand that any false or misleading information in my application or interview may result in my release.

Signature

Date